From the Guidelines
The workup of a patient with rectal prolapse begins with a thorough history and physical examination to confirm the diagnosis and identify potential causes, as recommended by the most recent guidelines 1.
Initial Evaluation
The initial evaluation should include:
- A thorough history to identify potential causes such as constipation, straining during defecation, prior childbirth trauma, and neurological conditions.
- A physical examination, including a digital rectal examination, to confirm the diagnosis and classify the prolapse as either complete (full-thickness rectal wall protrusion) or incomplete (mucosal prolapse only).
- Assessment for fecal incontinence, which affects 50-75% of patients with rectal prolapse.
Diagnostic Tests
The following diagnostic tests may be ordered:
- Defecography to evaluate the extent of prolapse and identify associated conditions like rectocele or enterocele.
- Colonoscopy to rule out malignancy or other colorectal pathology.
- Anorectal manometry to assess sphincter function, particularly important if the patient has fecal incontinence.
- Transit studies may be useful if constipation is a prominent symptom.
- Laboratory tests, including basic bloodwork to assess for anemia or other systemic conditions, as well as inflammatory markers such as C-reactive protein (CRP), procalcitonin (PCT), and lactate to evaluate the severity of the disease 1.
Surgical Evaluation
Once the evaluation is complete, determine if the patient is a surgical candidate, as surgery is the definitive treatment for rectal prolapse.
- The decision to perform laboratory tests to assess the severity of illness should be guided by the physical examination 1.
- In patients with complicated rectal prolapse, surgical treatment is recommended for those with signs of shock or gangrene/perforation of prolapsed bowel, and urgent surgical treatment is indicated for those with bleeding, acute bowel obstruction, or failure of non-operative management 1.
- The choice of surgical approach (abdominal versus perineal) should be based on the patient's age, comorbidities, and functional status, as well as the surgeon's skills and expertise 1.
Non-Surgical Management
For non-surgical candidates, conservative measures include:
- High-fiber diet
- Adequate fluid intake
- Stool softeners
- Pelvic floor exercises
- Non-operative management (NOM) may be attempted in patients with incarcerated rectal prolapse without signs of ischemia or perforation, but should not delay surgical treatment if manual reduction is not successful 1.
Pharmacological Regimen
In patients with strangulated rectal prolapse, empiric antimicrobial therapy is recommended due to the risk of intestinal bacterial translocation, and the appropriate regimen should be based on the clinical condition of the patient, the individual risk for multi-drug resistant organisms (MDRO), and the local resistance epidemiology 1.
From the Research
Diagnostic Evaluation
To work up a patient with rectal prolapse, the following steps can be taken:
- Physical exam to assess the extent of the prolapse and any associated symptoms such as pain, incomplete evacuation, or fecal incontinence 2, 3
- Colonoscopy to rule out any underlying colorectal conditions 2
- Anoscopy to evaluate the rectal mucosa and detect any internal prolapse 2
- Anal manometry and defecography in some patients to assess anorectal physiology and detect any abnormalities in bowel function 2
Medical Management
Medical management of rectal prolapse can be effective in some cases and may include:
- High-fiber diet and bulk laxatives to regulate bowel habits 4, 5
- Biofeedback therapy to improve anal sphincter function and continence 6
- Polyethylene glycol solutions and surface-active stool softeners such as docusate sodium to soften stool and reduce straining 5
Surgical Options
Surgical treatment is often necessary for rectal prolapse and may include:
- Abdominal or perineal approaches, with or without minimally invasive techniques 2
- Posterior or ventral rectopexy, with or without sigmoidectomy 2
- Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone's enema, and partial myotomy of the puborectalis muscle 4
- Laparoscopic ventral sacral colporectopexy, which may be an effective surgical option 4
- Mucosal resection (Delorme) or perineal proctectomy (Altemeier) for full-thickness prolapse (procidentia) 5